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Three Part Question

In an [otherwise healthy child presenting with acute diarrhoea] [does withholding milk feeds] [reduce the severity and duration of symptoms?]

Clinical Scenario

An 11 month old presents to the emergency department with diarrhoea. According to mum the child has had these symptoms for 3 days and this was preceded by one day of vomiting. On examinatoin she is mildly degydrated but is tolerating oral fluids well. Mum has been advised by the child's grandmother not to give her usual milk feeds as "it makes the diarrhoea worse". She asks you if this is the right thing to do?

Search Strategy

Ovid 1950-Nov 2008
Limit to Humans and child 0-18 years
{Diarrhea or Diarrhea or Diarrhoea).mp.}AND {oral rehydration therapy.mp. or Fluid Therapy}AND {milk.mp. or Milk}

Search Outcome

83 papers found of which 3 reviews articles and 6 RCTs were clinically relevent.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Allen, U D. McLeod, K. Wang, E.E Feb 1994 Canada	Infants 2-12 months of age with diarrhoea of less than one week's duration and mild or moderate dehydration. 39 infants received a soy-based formula and 34 received a cow's milk formula.	RCT	Duration of diarrhoea	Total duration of diarrhoea was significantly longer (p=0.03)in those receiving cow's milk	small numbers
March 1988 Israel	90 infants with mild dehydration and diarrhea. 53 were included in the early refeeding group and 37 in the late group using either breast or cow's milk	RCT	evaluation of weight, hydration state, stool frequency and need of hospitalisation	No significant difference between the groups
March 1988 India	60 children less than 2 years suffering from mild acute gastroenteritis randomly assigned to two different isocaloric feeding regimes.	RCT	Duration of diarrhoea, weight gain	Infants fed milk-free diet showed significantly less energy intake and gained weight less rapidly
Mar-Apr 1986	65 infants hospitalised for acute gastoenteritis. 27 infants had cow's milk and milk products eliminated from their diet. 38 infants received usual milk diet.	RCT	Duration of diarrhea	No significant difference between groups
Rees L, Brook CG April 1979	46 children with mild acute gastroenteritis randomly allocated to full-strength milk or clear fluids.	RCT	Length of hospital stay	No significant difference between the groups	small numbers

Comment(s)

There are a number of RCTS which address the question. All except one found no difference in the duration of diarrhoea in milk fed children. One study found a significantly reduced energy intake and weight gain in children on the milk free diet. The review articles which address the question all found that early re-introduction of a milk diet does not prolong the diarrhoea and is ntritionally beneficial. They all commented that the milk feeds should be in addition to oral rehydration therapy.

Clinical Bottom Line

Withholding milk feeds during an acute diarrhoeal illness in a child with mild dehydration does not shorten the length of the illness. In fact early reintroduction of milk (both breast and bottle) is nutritionally beneficial. This is in agreement with the World Health Organisation recommendations.

References

1. Allen, U D. McLeod, K. Wang, E. E Cow's milk versus soy-based formula in mild and moderate diarrhea: a randomised controlled trial
2. Brown KH, Peerson JM, Fontaine O. Use of nonhuman milks in the dietary management of young children with acute diarrhea: a meta-analysis of clinical trials.
3. Gazala E. Weitzman S. Weizman Z. Gross J. Bearman JE. Gorodischer R. Early Vs late refeeding in acute infantile diarrhea
4. Bhan MK. Arora NK. Khoshoo V. Raj P. Bhatnager S. Sazawal S. Sharma K. Comparison of a lactose-free cereal based formula and cow's milk in infants and children with acute gastroenteritis
5. Isolauri E. Vesikari T. Saha P. Viander M Milk versus no milk in rapid refeeding after acute gastroenteritis
6. Rees, L. Brook, C.G Gradual reintroductoin of full-strength milk after acute gastroenteritis in children